Welcome to Syracuse Orthopedic Surgeons - Patient Information

Request an Appointment:

Syracuse Orthopedic Specialists offers you the ability to securely
register for an appointment with our physicians on line.

To make an appointment, please complete the requested information below and submit it to us. A SOS scheduler will call you back to schedule an appointment. Please have your insurance information ready.
Please note: If you feel that you need care within the next 24 hours,
please call one of our offices by phone. Thank you!

* REQUIRED FIELDS
PATIENT INFORMATION:
PATIENT NAME*:
DATE OF BIRTH*:(mm/dd/yyyy)
Address*:
Home Phone*:
Work Phone:
Cell Phone:
Patient’s Employer:
Referring Physician*:
Phone Number:
Request Appt. for*:	Initial Visit Second Opinion New Problem Return Visit
TREATMENT REQUIRED FOR: Hip Knee Hand Spine Shoulder Elbow Foot/Ankle Please specify Other:
Do you have a SOS Physician of preference?
PREFERRED OFFICE LOCATION: 5719 Widewaters Parkway, Dewitt (315) 251-3100 5000 West Seneca Turnpike Office, Syracuse (315) 492-3636 4888 West Taft Rd., Liverpool (315) 453-4567 5700 West Genesee St., Camillus (315) 487-4876 North Medical Center 5100 West Taft Rd., Liverpool (315) 452-2120 Northeast Medical Center 4115 Medical Center Dr., Fayetteville (315) 329-7600
ANY PREVIOUS TREATMENT NEEDS TO BE DOCUMENTED BELOW:
Symptoms*:
Diagnosis:
Treatment has included*:
Treating Physician(s):
Tests Performed*: X-ray MRI Nerve Testing PT Other:
Was Surgery Recommended*: Yes No If so, what?:
When?*: (mm/dd/yyyy): By Whom:
Surgery Details (if any):
Why is patient changing Doctor (if applies)?:
*PRIMARY INSURANCE INFORMATION:**
Company:
Billing Address:
Insurance Co Phone:
Subscriber’s Name:
Subscriber’s DOB (mm/dd/yyyy):
ID #:
Group #:
*SECONDARY INSURANCE:**
Company:
Billing Address:
Insurance Co Phone:
Subscriber’s Name:
Subscriber’s DOB (mm/dd/yyyy):
ID #:
Group #:
WORKMAN’S COMPENSATION (work-injury)*:
Employer at the time of injury:
Insurance Carrier Name:
Insurance Carrier Address:
Carrier Phone#:
Claim #:
Policy #:
Date of Injury (mm/dd/yyyy):
Authorized for Treatment of (body part):
*No Fault Information:**
Accident Date:
Insurance Carrier Name:
Insurance Carrier Address:
Contact Phone #:
Claim #:
EMERGENCY CONTACT INFORMATION:
Name:
DOB(mm/dd/yyyy):
Phone:
Relationship to Patient:
How did you hear about SOS?:

Please submit one appointment request per patient. If you do not hear from us within 2 business days after submission of this request, please contact our office. Thank you.